2016_0916 IRRIGATION v DOMESTIC FIRELINE
The following form must be completed for each assembly tested. A signed and dated original
must be submitted to the public water supplier for recordkeeping purposes:
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL PWS I.D. # 0570040
(Customer)
MAILING ADDRESS:
CONTACT PERSON/PHONE:
LOCATION OF SERVICE: /�9 LvsKi�'/�-/�
The backflow prevention assembly detailed below has been tested and maintained as required by
commission regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
'� Reduced Pressure Principle -1Reduced Pressure Principle-Detector
�LSouble Check Valve I���Double Check-Detector
IPressureVacuumBreaker [iSpill-Resistant Pressure Vacuum Breaker
� �Manufacturer d!/� [�i�i✓s Model Number �,,5 C� Size
Located At /%/l.�iy�/�}-/L� Serial Number/tS�S^`3'� v
Is the assembly installed in accordance with manufacturer recommendations and/or local codes?,� CS
Reduced Pressure Princi le Assembl Pressure Vacuum Breaker
Double Check Valve Assembly
Relief Valve Air Inlet Check Valve
1 st Check 2nd Check
Neld�'� psid Held a� �sid Opened at Opened at Held at
Initial Test Closed Tight���r Closed Tight I�/'� psid psid psid
Leakedf 1 Leaked.�I Did not open I���� Did not open �� ' Leakedi
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair ClosedTight[ ClosedTight[�.i psid psid psid
Test gauge used: Make/Model �0���� �Sd�� / F?�i SN�d�7��+ �� 7
Date Tested for Accuracy: ���.'ig�/L
Remarks:
The above is certified to be true at the time of tesring.
Firm Name_�� .��� Firm Address��r�`����i��//L`'� ✓C�fjtjr'� �
�1? ►u�l-�G �8v��c`
Certified Tester(pr3nt)�' Certified Tester(signature ..,�����
Firtn Phone# �7.�-'��� �,i� Cert.Tester No�S g?� Date��li ��G
* TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
**USE ONLY MANUFACTURER'S REPLACEMENT PARTS
White-City Copy Yellow-Customer Copy Pink-Tester's Copy